Questionable Billing for Medicaid Pediatric Dental Services in California

WHY WE DID THIS STUDY

Medicaid is the primary source of dental coverage for children in low-income families and provides access to dental care for approximately 37 million children. In recent years, a number of dental providers and chains have been prosecuted for providing unnecessary dental procedures to children with Medicaid and causing harm in the process. This report is part of a series that identifies dental providers with questionable billing in four States: New York, Louisiana, Indiana, and California. An additional report will look at children's access to Medicaid dental care.

HOW WE DID THIS STUDY

We analyzed paid fee-for-service claims from California's Medicaid program for general dentists and orthodontists who served 50 or more children with Medicaid in 2012. Using several measures, we identified dental providers with questionable billing who are extreme outliers when compared to their peers in California.

WHAT WE FOUND

We identified 329 general dentists and 6 orthodontists in California with questionable billing. Medicaid paid these providers $117.5 million for pediatric dental services in 2012. These 335 dental providers-representing 8 percent of the California general dentists and orthodontists whom we reviewed-provided large numbers of services or provided certain services to an extremely large number of children, among other practices. These services included pulpotomies-often referred to as "baby root canals"-and extractions. Notably, half of the dental providers with questionable billing in California worked for dental chains. The majority of these providers worked for five chains, two of which have been the subject of State and Federal investigations. A concentration of providers with questionable billing in chains raises concerns that these chains may be encouraging their providers to perform unnecessary procedures to increase profits.

Further, our findings raise concerns that certain providers may be billing for services that are not medically necessary or were never provided. They also raise concerns about the quality of care provided to children with Medicaid. Although our findings do not prove that providers either billed fraudulently or provided medically unnecessary services, providers with extreme billing patterns warrant further scrutiny. We are engaged in further followup and OIG will take action against these providers, as appropriate.

WHAT WE RECOMMEND

We recommend that the California Department of Health Care Services (1) increase its monitoring of dental providers to identify patterns of questionable billing; (2) closely monitor billing by providers in dental chains; (3) review its payment processes for orthodontic services; and (4) take appropriate action against dental providers with questionable billing. The California Department of Health Care Services concurred with all four of our recommendations.